DARDR / SAR Peter (2021)

This joint Domestic Homicide Review (DHR) and Safeguarding Adults Review (SAR) examines the circumstances surrounding the death of Peter, aged 55, who was murdered in March 2018 by a man living in his household.

Peter had a long history of alcohol dependence, cognitive impairment, and self-neglect, and was known to multiple agencies for mental health and substance misuse issues. The review highlights missed opportunities to initiate safeguarding processes despite repeated indicators of exploitation, coercion, and financial abuse by so-called friends, culminating in the perpetrator’s control over Peter’s home and finances.

Key learning themes include:

• Gaps in practitioners’ understanding of domestic abuse beyond intimate relationships
• Failure to apply the Mental Capacity Act in the context of fluctuating capacity
• Insufficient multi-agency coordination—particularly around housing options and risk management
• The need for improved safeguarding responses for adults with complex needs and trauma-informed practice
• Better integration of housing and health services
• Enhanced training on coercion, control, and alcohol-related vulnerabilities to prevent similar tragedies.

These lessons aim to strengthen safeguarding responses and prevent similar tragedies in the future.

DHR in the case of Peter executive summary (PDF, 317kb)

DHR in the case of Peter overview report (PDF, 550kb)

Feedback letter from the Home Office in the case of Peter (PDF, 87kb)